Trizepitide/Semaglutide/Peptide

Injection Form

Please fill in the form below

Full Name *

Email *

Sex

Male

Female

Other

Date of birth *

Phone *

Address: *

City *

State *

Country

Postal code *

Emergency Contact name and Phone Number: *

Physician Name and Phone:

How did you hear about us? *

Medical History

Please describe the reaction you experienced:

Taking any medications, currently? *

Yes

If yes, please list it here *

Female Clients

Are you pregnant or trying to become pregnant? *

Yes

If pregnant what week of pregnancy are you in?

Are you breastfeeding?

Yes

Contraindications

I certify that I do not have any of the following contraindications. *

• diabetic retinopathy • low blood sugar of unknow origin • decreased kidney function • pancreatitis • medullary thyroid cancer • multiple endocrine neoplasia type 2 • family history of medullary thyroid carcinoma • kidney disease with likely reduction in kidney function

Patient Agreement

I agree to the following please initial each sentence: *

I am responsible for my medicines. I will not share, sell, or trade my medicine. I will not take anyone else’s medicine.

I will not increase my medicine until I speak with my doctor or nurse.

My medicine may not be replaced if it is lost or stolen.

I will keep all appointments set up by my provider.

I understand the contraindications and the provider has answered all asked questions.

Informed Consent

I certify that the preceding medical, medication and personal history statements are true and correct. I am aware that it is my responsibility to inform Dr. Taylor and Yvonne Alvarez RN of my current medical or health conditions and to update this history. A current medical history is essential to execute appropriate treatment procedures. I agree to receive treatment from Dr. Taylor and or Yvonne Alvarez RN.

I understand these peptides are not FDA approved and assume my own risk while using these peptides.

If I break any of the rules, or if my provider decides that this treatment is not benefiting me or helping me, this medicine may be stopped by my provider. I have talked about this agreement with my provider, and I understand the above rules.

Please Type Your Full Name as Signature of agreement of Informed Consent and certification statement. *

Date *

Medical Director - Dr. Frank DiMotta, Dr. Jill Sohayda, and Dr. Jeff McKinley